Endocrine Abstracts

A 27 year old lady presented in 2016 with a 3 month history of intermittent headache and visual disturbance, 3.5 months post-partum. She had a past medical history of cluster headache; treated with verapamil and short courses of oral steroids (she had no recent steroid courses prior to presentation). She was found to have a partial right sixth nerve palsy but normal visual fields on Goldmann’s testing. She had biochemical evidence of secondary adrenal insufficiency (sodium 120 mmol/l, random cortisol 31 nmol/l) and hypogonadotrophic hypogonadism (oestradiol <50 pmol/l, LH 3 iU/l, FSH < 1iU/l). She also had polyuria and polydipsia, blood and urine tests were consistent with mild diabetes insipidus. Urgent MRI showed a complex pituitary mass, with suprasellar extension and optic chiasm impingement, thought initially to be a craniopharyngioma. She was commenced on hydrocortisone replacement and desmopressin with good effect. Review of previous MRIs to investigate headaches showed the lesion was not previously present, hence it was unlikely to be a craniopharyngioma. She underwent trans-sphenoidal adenomectomy in November 2016 – unexpectedly, pus was aspirated which was positive for Strep pneumoniae, H. influenzae and Staph epidermidis. Histology showed granulomatous inflammation within a Rathke’s cleft cyst. Her adrenal insufficiency and diabetes insipidus resolved post-operatively, but she still had evidence of hypogonadotrophic hypogonadism. Three years following initial presentation, she was re-referred urgently with recurrent polyuria and polydipsia. Reassessment showed central hypothyroidism (TSH 0.19 mU/l, fT4 10.3 pmol/l, ft3 2.7 pmol/l), persistence of hypogonadotrophic hypogonadism (oestradiol <60 pmol/l, LH 6.9 iU/l, FSH 2.5 iU/l) and diabetes insipidus (sodium 145 mmol/l, serum osmolality 294 mmol/kg; urine osmolality 142 mmol/kg). MRI confirmed a recurrence of a loculated pituitary lesion – she underwent further trans-sphenoidal drainage in Oct 2019, but cultures were negative for any pathogens this time.

In addition, she then developed diarrhoea and mouth ulcers, which prompted investigations under the gastroenterology team. Colonoscopy has shown active inflammation within the ileum and colon, and she is being treated for presumed Crohn’s disease. Tests for syphilis, blood-borne viruses, sarcoidosis and vasculitis have been negative. Pituitary abscesses are extremely rare (0.2–1% of all pituitary disease) – it is even rarer to have recurrent episodes in the absence of any systemic immunosuppression or pituitary irradiation. Only 8 previous cases of recurrent pituitary abscess have been reported in the literature. Additionally, we discuss whether this patient could have an underlying multi-system condition driving multi-organ inflammation; or whether her pituitary issues could be an extra-intestinal manifestation of inflammatory bowel disease.